Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 2To ensure prompt attention to your claim, please complete this form in full and submit it to us as soon as possible. NOTE Ensure the accident description is accurate and all questions on the claim form have been answered in full. Please provide a copy of a valid driver licence and vehicle registration papers when submitting this claim form. If you do not tell us or do not answer our questions accurately or fail to disclose relevant information, we may reduce or refuse to pay a claim. If you answer our questions fraudulently, we may refuse to pay a claim and treat this claim as never having been in force. Check list to process to the claim. Please tick the boxes for available documents. *Rego Paper*Owner Driver License*Driver’s Driver License*At fault Party Driver License*Photos from the scene of accidentAny out-of-Pocket expense (Tow invoice etc.)Attach Documents * Drag & Drop Files, Choose Files to Upload You can upload up to 10 files. Please attach the documents you have ticked as per aboveWe may request you to provide relevant documentation to enable us to complete consideration of your claim. IMPORTANT NOTICES This claim form is incomplete and cannot be processed if you do not provide the required documents marked with an asterisk (*). FOR OFFICE STAFF Please make sure that you have attached the printed copy of the required documents. NextOwner’s DetailsName *FirstLastResidential Address: *Post Code *Suburb *Phone *Email *Driver DetailsName *FirstLastResidential Address (Driver Details) *Post Code *Suburb *D.O.B *Licence Number *Expiry *State Of Issue *--- Select Choice ---NSWVICQLDSAWATASACTNTOVERSEAS STATECountry Of Issue *Select CountryAustraliaAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChileChinaColombiaComorosCongo (Congo-Brazzaville)Costa RicaCroatiaCubaCyprusCzech Republic (Czechia)Democratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (fmr. "Swaziland")EthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (formerly Burma)NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorth MacedoniaNorwayOmanPakistanPalauPalestine StatePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweChoice 199Motor Vehicle DetailsMake *Model *Year *Rego* *Kms *Type of Use *PrivateBusiness)Any Pre-existing damage to your vehicle (Please choose) *YesNoDamages SustainedAREA DAMAGE Incident DescriptionDate *Time *Place of accident *Suburb *Post Code *Road Condition *DryWetDaylightNightWere You *StationaryMovingEstimated Speed of your vehicle in kms *Who was responsible for the collision and why? *Did any driver accept the liability *YesNoif ‘’yes” whom *Accident DescriptionAccident Description *Enter Accident Description to the best of your knowledgeOr Upload Your Own Drawings and Photos Drag & Drop Files, Choose Files to Upload You can upload up to 5 files. Passenger Details (If Any)NameFirstLastPhoneAddress of Passenger DetailsWitness Details (If Any)NameFirstLastPhone (of Witness)At fault Party Details (Attach Extra Sheet for more than 1 at fault party)Name *FirstLastResidential Address *Post Code *Suburb *Phone *DOB *Licence NumberExpiry *State of issue *--- Select Choice ---NSWVICQLDWASAACTTASNTCountry of Issue *--- Select Choice ---AustraliaAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChileChinaColombiaComorosCongo (Congo-Brazzaville)Costa RicaCroatiaCubaCyprusCzech Republic (Czechia)Democratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (fmr. "Swaziland")EthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (formerly Burma)NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorth MacedoniaNorwayOmanPakistanPalauPalestine StatePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweChoice 199At Fault Party Vehicle & Insurance DetailsMake & Model *Year *Rego *Claim Number *Policy NumberDeclaration *YES, I agreeI declare that, to the best of my knowledge and belief, the information in this form is true and correct and I understand the claim may be refused or reduced if information is withheld. I understand that I may have to provide relevant documentation to enable complete consideration of my claim. I consent to SR Smash Solutions using the personal information (including sensitive information) I have provided on this form for the purposes of processing my claim. I consent to the disclosure of personal information (including sensitive information) to third parties in order to process my claim. I consent to the disclosure of any personal information (including sensitive information) overseas where it is reasonably necessary for the processing of my claim.Date *AUTHORISATION/DIRECTION TO ACT ON MOTOR VEHICLE DAMAGE CLAIMName [Authority to Act] *FirstLastRegistration Number *As per the name above, I acknowledge that I am the registered owner of the motor vehicle with the registration number stated above. *YesAuthority & Declaration: Authority and Direction I hereby authorise and direct SR Smash Solutions, in the State of New South Wales, as follows: To act on my behalf as an agent/authorised representative in relation to my claim. To obtain quotations, reports, invoices, photographs, and other documents to support my claim. To claim damages related to repairs and hire car, negotiate, settle, and manage all correspondence concerning my motor vehicle claim. To obtain an independent assessor report to substantiate my losses. To retain legal representatives to act on my behalf and to be responsible for the payment of all legal costs and disbursements. I irrevocably authorise SR Smash Solutions to sign on my behalf any acknowledgements or releases required to settle my/our claim, and to direct settlement cheques to be made payable to the legal representative for the deduction of fees and repair costs. I acknowledge that if SR Smash Solutions decides, for any reason, to no longer act on my behalf, no fee will be payable to SR Smash Solutions. I acknowledge that if I withdraw my claim without the consent of SR Smash Solutions, I will be responsible for all fees incurred, including assessment and legal fees. I certify that there are reasonable grounds for proving the facts of my claim and that it has reasonable prospects of success. I acknowledge that statements may be required from me, my driver, assessor, or witnesses if the claim proceeds to litigation. I release and indemnify SR Smash Solutions from any present or future claims arising from their actions taken on my behalf in relation to my claim. This authority remains in effect until I revoke it in writing. I declare that the above-mentioned particulars are true and correct. AUTHORITY TO PAY I authorize SR Smash Solutions receive payments on my behalf, the full cost of repairs and / or Loss as per the invoiced / assessed quotation report. *I, AgreeDate / Time *Submit
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